To clarify whether bowel preparation use or its individual components mechanical bowel preparation (MBP)/oral antibiotics impact specific outcomes after colorectal surgery.
National Surgical Quality ...Improvement Program-targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP+/ABX+), MBP alone (MBP+/ABX-), and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, surgical site infection (SSI), and ileus, were evaluated using unadjusted/adjusted logistic regression analysis.
Of 8442 patients, 2296 (27.2%) had no-prep, 3822 (45.3%) MBP+/ABX-, and 2324 (27.5%) MBP+/ABX+. Baseline characteristics were similar; however, there were marginally more patients with prior sepsis, ascites, steroid use, bleeding disorders, and disseminated cancer in no-prep. MBP with or without antibiotics was associated with reduced ileus MBP+/ABX+: odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.48-0.68; MBP+/ABX-: OR = 0.78, 95% CI: 0.68-0.91 and SSI MBP+/ABX+: OR = 0.39, 95% CI: 0.32-0.48; MBP+/ABX-: OR = 0.80, 95% CI: 0.69-0.93 versus no-prep. MBP+/ABX+ was also associated with lower anastomotic leak rate than no-prep OR = 0.45 (95% CI: 0.32-0.64). On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR = 0.57, 95% CI: 0.35-0.94), SSI (OR = 0.40, 95% CI: 0.31-0.53), and postoperative ileus (OR = 0.71, 95% CI: 0.56-0.90).
These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery.
Aim
The current COVID‐19 pandemic is challenging healthcare systems at a global level. We provide a practical strategy to reorganize pathways of emergency and elective colorectal surgery during the ...COVID‐19 pandemic.
Method
The authors, all from areas affected by the COVID‐19 emergency, brainstormed remotely to define the key‐points to be discussed. Tasks were assigned, concerning specific aspects of colorectal surgery during the pandemic, including the administrative management of the crisis in Italy. The recommendations (based on experience and on the limited evidence available) were collated and summarized.
Results
Little is known about the transmission of COVID‐19, but it has shown a rapid spread. It is prudent to stop non‐cancer procedures and prioritize urgent cancer treatment. Endoscopy and proctological procedures should be performed highly selectively. When dealing with colorectal emergencies, a conservative approach is advised. Specific procedures should be followed when operating on COVID‐19‐patients, using dedicated personal protective equipment and adhering to specific rules. Some policies are described, including minimally‐invasive surgery. These policies outline the strict regulation of entry/ exit into theatres and operating building as well as advice on performing procedures safely to reduce risk of spreading the virus. It is likely that a reorganization of health system is required, both at central and local levels. A description of the strategy adopted in Italy is provided.
Conclusion
Evidence on the management of patients needing surgery for colorectal conditions during the COVID‐19 pandemic is currently lacking. Lessons learnt from healthcare professionals that have managed high volumes of surgical patients during the pandemic could be useful to mitigate some risks and reduce exposure to other patients, public and healthcare staff.
All colorectal surgeons are faced from time to time with anastomotic leakage after colorectal surgery. This complication has been studied extensively without a significant reduction of incidence over ...the last 30 years. New techniques of prevention, by innovative anastomotic techniques should improve results in the future, but standardization and "teachability" should be guaranteed. Risk scoring enables intra-operative decision-making whether to restore continuity or deviate. Early detection can lead to reduction in delay of diagnosis as long as a standard system is used. For treatment options, no firm evidence is available, but future studies could focus on repair and saving of the anastomosis on the one hand or anastomotical breakdown and definitive colostomy on the other hand.
Purpose
This study aimed to quantitatively evaluate colon perfusion patterns using indocyanine green (ICG) angiography to find the most reliable predictive factor of anastomotic complications after ...laparoscopic colorectal surgery.
Methods
Laparoscopic fluorescence imaging was applied to colorectal cancer patients (
n
= 86) from July 2015 to December 2017. ICG (0.25 mg/kg) was slowly injected into peripheral blood vessels, and the fluorescence intensity of colonic flow was measured sequentially, producing perfusion graphs using a video analysis and modeling tool. Colon perfusion patterns were categorized as either fast, moderate, or slow based on their fluorescence slope,
T
1/2MAX
and time ratio (TR =
T
1/2MAX
/
T
MAX
). Clinical factors and quantitative perfusion factors were analyzed to identify predictors for anastomotic complications.
Results
The mean age of patients was 65.4 years, and the male-to-female ratio was 63:23. Their operations were laparoscopic low anterior resection (55 cases) and anterior resection (31 cases). The incidence of anastomotic complication was 7%, including colonic necrosis (
n
= 1), anastomotic leak (
n
= 3), delayed pelvic abscess (
n
= 1), and delayed anastomotic dehiscence (
n
= 1). Based on quantitative analysis, the fluorescence slope,
T
1/2MAX
, and TR were related with anastomotic complications. The cut-off value of TR to categorize the perfusion pattern was determined to be 0.6, as shown by ROC curve analysis (AUC 0.929,
P
< 0.001). Slow perfusion (TR > 0.6) was independent factor for anastomotic complications in a logistic regression model (OR 130.84; 95% CI 6.45–2654.75;
P
= 0.002). Anastomotic complications were significantly correlated with the novel factor TR (> 0.6) as the most reliable predictor of perfusion and anastomotic complications.
Conclusions
Quantitative analysis of ICG perfusion patterns using
T
1/2MAX
and TR can be applied to detect segments with poor perfusion, thereby reducing anastomotic complications during laparoscopic colorectal surgery.
Background
Fluorescence technology with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. However, a subjective evaluation of fluorescence intensity based on the ...surgeon’s visual judgement is a major limitation. This study evaluated the quantitative assessment of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery.
Methods
This is a retrospective analysis of a prospectively maintained database of 112 patients who underwent laparoscopic surgery for left-sided colorectal cancers. After distal transection of the bowel, the specimen was extracted extracorporeally and then the proximal colon was divided within the well-perfused area based on the ICG fluorescence imaging. We evaluated whether quantitative assessment of intestinal perfusion by measuring ICG intensity could predict postoperative outcomes:
F
max
,
T
max
,
T
1/2,
and
Slope
were calculated.
Results
Anastomotic leakage (AL) occurred in 5 cases (4.5%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an “adequate” fluorescent portion in 18 cases (16.1%). Among the 18 patients, AL occurred in 4 patients (4/18: 22.2%), whereas it occurred in only 1 case (1/94: 1.0%) in the good perfusion patients who did not need proximal change of the transection line. The
F
max
of the AL group was less than 52.0 in all 5 cases (5/5), whereas that of the non-AL group was in only 8 cases (8/107): with an
F
max
cutoff value of 52.0, the sensitivity and specificity for the prediction of AL were 100 and 92.5%, respectively. Regarding postoperative bowel movement recovery, the
T
max
of the early flatus group or early defecation group was significantly lower than that of the late flatus group or late defecation group, respectively.
Conclusions
ICG fluorescence imaging is useful for assessing anastomotic perfusion in colorectal surgery, which can result in more precise operative decisions tailored for an individual patient.
The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability.
To examine whether state-level malpractice environment is associated with ...outcomes and costs of colorectal surgery.
Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure. Associations between malpractice environment and postoperative outcomes and price-standardized Medicare payments were estimated using hierarchical logistic regression and generalized linear models.
thirty-day postoperative mortality; complications (pneumonia, myocardial infarction, venous thromboembolism, acute renal failure, surgical site infection, postoperative sepsis, any complication); readmission; total price-standardized Medicare payments for index hospitalization and 30-day postdischarge episode-of-care.
Few associations between measures of state malpractice risk environment and outcomes were identified. However, analyses using the composite measure showed that patients treated in states with greatest malpractice risk were more likely than those in lowest risk states to experience any complication (OR: 1.31; 95% CI: 1.22-1.41), pneumonia (OR: 1.36; 95%: CI, 1.16-1.60), myocardial infarction (OR: 1.44; 95% CI: 1.22-1.70), venous thromboembolism (OR:2.11; 95% CI: 1.70-2.61), acute renal failure (OR: 1.34; 95% CI; 1.22-1.47), and sepsis (OR: 1.38; 95% CI: 1.24-1.53; all P < 0.001). There were no consistent associations between malpractice environment and Medicare payments.
There were no consistent associations between state-level malpractice risk and higher quality of care or Medicare payments for colorectal surgery.
Background
Pelvic exenteration for locally recurrent rectal cancer (LRRC) is associated with variable outcomes, with the majority of data from single‐centre series. This study analysed data from an ...international collaboration to determine robust parameters that could inform clinical decision‐making.
Methods
Anonymized data on patients who had pelvic exenteration for LRRC between 2004 and 2014 were accrued from 27 specialist centres. The primary endpoint was survival. The impact of resection margin, bone resection, node status and use of neoadjuvant therapy (before exenteration) was assessed.
Results
Of 1184 patients, 614 (51·9 per cent) had neoadjuvant therapy. A clear resection margin (R0 resection) was achieved in 55·4 per cent of operations. Twenty‐one patients (1·8 per cent) died within 30 days and 380 (32·1 per cent) experienced a major complication. Median overall survival was 36 months following R0 resection, 27 months after R1 resection and 16 months following R2 resection (P < 0·001). Patients who received neoadjuvant therapy had more postoperative complications (unadjusted odds ratio (OR) 1·53), readmissions (unadjusted OR 2·33) and radiological reinterventions (unadjusted OR 2·12). Three‐year survival rates were 48·1 per cent, 33·9 per cent and 15 per cent respectively. Bone resection (when required) was associated with a longer median survival (36 versus 29 months; P < 0·001). Node‐positive patients had a shorter median overall survival than those with node‐negative disease (22 versus 29 months respectively). Multivariable analysis identified margin status and bone resection as significant determinants of long‐term survival.
Conclusion
Negative margins and bone resection (where needed) were identified as the most important factors influencing overall survival. Neoadjuvant therapy before pelvic exenteration did not affect survival, but was associated with higher rates of readmission, complications and radiological reintervention.
Complete resection is key
There is growing interest in using patient-reported outcome measures to support value-based care in colorectal surgery. To draw valid conclusions regarding patient-reported outcomes data, measures ...with robust measurement properties are required.
The purpose of this study was to assess the use and quality of patient-reported outcome measures in colorectal surgery.
Three major databases were searched for studies using patient-reported outcome measures in the context of colorectal surgery.
Articles that used patient-reported outcome measures as outcome for colorectal surgical intervention in a comparative effectiveness analysis were included. Exclusion criteria included articles older than 11 years, non-English language, age <18 years, fewer than 40 patients, case reports, review articles, and studies without comparison.
This was a quality assessment using a previously reported checklist of psychometric properties.
From 2007 to 2018, 368 studies were deemed to meet inclusion criteria. These studies used 165 distinct patient-reported outcome measures. Thirty were used 5 or more times and were selected for quality assessment. Overall, the measures were generally high quality, with 21 (70%) scoring ≥14 on an 18-point scale. Notable weaknesses included management of missing data (14%) and description of literacy level (0%).
The study was limited by its use of original articles for quality assessment. Measures were selected for quality analysis based on frequency of use rather than other factors, such as impact of the article or number of patients in the study.
Patient-reported outcome measures are widely used in colorectal research. There was a wide range of measures available, and many were used only once. The most frequently used measures are generally high quality, but a majority lack details on how to deal with missing data and information on literacy levels. As the use of patient-reported outcome measures to assess colorectal surgical intervention increases, researchers and practitioners need to become more knowledgeable about the measures available and their quality.
Background
Laparoscopic surgery and enhanced recovery after surgery (ERAS) programs were two major improvements for the management of colorectal diseases. The purpose of this systemic review was to ...examine whether laparoscopic colorectal surgery still improved short-term postoperative outcomes in comparison with open surgery when both groups of patients received ERAS programs.
Methods
PubMed, Embase, the Cochrane Central Register of Controlled Trials, and reference lists of the identified studies were searched to identify randomized clinical trials that compared laparoscopic with open surgery in patients undergoing colorectal resection in the context of ERAS programs. The outcome measures were analyzed, and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.
Results
Five randomized clinical trials encompassing 598 patients were included in the final analysis. Two of them were multicenter trials. The ERAS programs implemented in the five included trials cannot be classified as optimal ERAS programs, but suboptimal ERAS programs. Laparoscopic colorectal surgery significantly reduced total hospital stay (weighted mean difference (WMD) −1.92 days; 95 % confidence interval (CI) −2.61–−1.23 days;
P
< 0.00001) and number of complications (relative risk (RR) 0.78; 95 % CI 0.66–0.94;
P
= 0.007) compared with open surgery in the setting of ERAS programs. No significant differences were found between groups for primary hospital stay, number of patients with complications, readmission rates, and mortality. The quality of evidence for all outcomes was low-to-moderate on the GRADE scale, and none had high quality.
Conclusions
Laparoscopic colorectal resection significantly reduced total hospital stay and number of complications when compared with open surgery in the setting of suboptimal ERAS programs, but the benefits of laparoscopic colorectal resection remain to be proved within optimal ERAS programs.
PDF
